ATI Custom Med/Surg III Review

A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Start slowly and increase volume over several sessions

A nurse is preparing to administer an enteral feeding via an established NG tube. Identify the sequence the nurse should follow to initiate the feeding.

1. Verify tube placement 2. Check the residual feeding contents. 3. Administer the feeding. 4. Evaluate tolerance to the feeding.

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is prescribed to receive 40 mL of fluid replacement every 4 hr for each 100 mL of output. The clients output over the last 4 hr was 250 mL. How much water should the nurse administer to the client?

100mL

A nurse in the newborn nursery is receiving report on 4 newborns. Which of the following newborns should the nurse see first?

A newborn who is 12 hours old and has an axillary temp of 100*

A nurse is caring for a client who has skeletal traction for treatment of a femur fracture. Which of the following actions should the nurse take?

Administer pain medication to the client before performing pin care

A nurse is caring for a client who is 2 days postoperative from abdominal surgery. The client reports discomfort from abdominal distention and flatus. Which of the following suggestions should the nurse include?

Ambulate several times a day.

A nurse is reviewing laboratory findings for a client admitted with multiple myeloma. The nurse should expect to see an increase in which of the following laboratory tests?

Calcium

A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

Cover the client's wound with a moist, sterile dressing

A nurse is caring for a client who is at 34 weeks gestation and has a suspected placenta previa. Which of the following actions should the nurse take?

Apply an external fetal monitor

A nurse in a provider's office is reinforcing teaching with a client who is to collect a 24 hour urine specimen. Which of the following instructions should the nurse include in the teaching?

At the beginning of the collection time, urinate and then discard the urine, collect after that

A nurse is reinforcing teaching with a client who has neutropenia. Which of the following instructions should the nurse include in the teaching?

Avoid crowed places

A nurse is reinforcing teaching with a group of clients about first aid care for a bee sting . Which of the following information should the nurse reinforce in the teaching?

Remove the stinger by scraping it off

A nurse is reinforcing dietary teaching with a client who has GERD. Which of the following food choices by the client indicates and understanding?

Baked turkey breast

A nurse is caring for a client receiving chemotherapy. The nurse should identify that a client who has myelosuppression is at risk for which of the following conditions?

Bleeding from the gums

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

Breathe in through her nose and out through pursed lips.

A nurse is preparing a 4-year old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the patient which of the following instructions?

Call the healthcare clinic to report that the tubes have fallen out

A nurse is assisting with the care of a 14 year old client in the emergency department (ED) who has anorexia nervosa. Which of the following 5 findings require immediate follow up by the nurse?

Capillary refill Magnesium level Sodium level Glucose level Blood pressure

A nurse is inserting an intravenous catheter for a client which results in blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following action should the nurse take?

Carefully remove the glove and follow with hand hygine

A nurse is assisting with the care of a client 2 hours postoperative following a catheterization. Which of the following actions should the nurse take?

Check the clients distal pulses in both legs

A nurse is working with community members to prepare for an external disaster. The nurse is assisting the community members to compile a list of basic supplies needed in the case of a disaster. Which of the following supplies should the nurse instruct the community members to include? Select all that apply.

Clean clothing Personal identification Matches

A nurse is collecting data from a client who is to have an intravenous pyelogram(IVP). Which of the following data is a contraindication to this procedure?

Client has an allergy to shellfish

A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?

Client's self-report of pain

A nurse is caring for a 3-year-old child who weighs 33 lb and has had 160 mL of urine output during the past 8 hr. Which of the following actions should the nurse take?

Continue to monitor the client

A nurse is reinforcing teaching with a client who has cancer about foods that prevent protein -energy malnutrition. Which of the following should the nurse include in the teaching? (Select All That Apply)

Cottage cheese Milkshake Egg and ham omelet

A nurse is reviewing data for a client who has chronic kidney disease. Which of the following data should the nurse identify as the best indicator of fluid volume status?

Daily weight

A nurse is assisting with the care of a client who is receiving a blood transfusion. Which of the following findings should the nurse report to the provider?

Difficulty breathing

A nurse is conducting a preoperative interview with a client who is scheduled for surgery. The client states that he takes acetylsalicylic acid 81 mg by mouth daily. Prior to the clients upcoming surgery, the nurse should instruct the client to do which of the following?

Discontinue the dose two weeks before surgery

A nurse is reinforcing teaching with a client's family about lightning strike prevention following a lightning injury to the client. Which of the following information should the nurse reinforce in the teaching?

Do not use a corded landline phone

A nurse is reinforcing teaching with a client who has a colostomy about appropriate food choices. Which of the following foods should the nurse include?

Dried fruits

A nurse is caring for a client who has recently fallen. Complete the following sentence by using the list of options.

Drowsiness Pain right shoulder

A nurse is caring for a client who has liver cirrhosis with ascites and bleeding esophageal varies. Which of the following laboratory findings indicates that the clients gastrointestinal(GI) tract is digesting and absorbing blood?

Elevated BUN

A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

Empty her bladder immediately prior to the procedure

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. The client's BUN is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following actions should the nurse take?

Evaluate urine output for amount and urine for specific gravity

A nurse is checking the laboratory results of a client who is at risk for diabetes mellitus. Which of the following laboratory results indicates to the nurse that the client is at risk for diabetes mellitus?

Fasting blood glucose 155

A nurse is reviewing a client's medical record. Which of the following laboratory tests should the nurse examine to determine risk factors for metabolic syndrome?

Fasting glucose and triglycerides

A nurse is caring for a 7 year-old client who has an upper respiratory infection and a history of type 1 DM. Which of the following statements by the mother indicates a need for further instructions?

I will continue to check his blood sugar two times every day

A nurse is reinforcing teaching with a client who is pregnant and has hyperemesis gravidarum about nutrition at home. Which of the following statements indicates that the client understands the teaching?

I will eat crackers before i get out of bed in the morning

A nurse is reinforcing teaching with a client who has Crohn's disease about foods to include in her diet. Which of the following foods should the nurse include in the teaching?

Grilled chicken breast

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

Have the client ambulate frequently in the hallway

A nurse is collecting data from a client who is 3 hr. postpartum. The nurse notes that the client's fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse take?

Have the client urinate

A nurse is reinforcing teaching about Rho(D) immunoglobulin to a client who is pregnant. Which of the following findings can an Rh incompatibility cause?

Hydrops fetalis

A nurse is reinforcing teaching about a heart healthy diet with a group of clients who have hypertension. Which of the following statements by the client indicates a need for further teaching?

I can have a cola drink twice a day

A nurse is assisting with teaching a group of clients about monitoring for diabetic peripheral neuropathy. Which of the following client statements indicates understanding of the information?

I might lose awareness of when I'm stepping on a harmful object

A nurse is reinforcing teaching about ileostomy care with a client. The nurse should recognize which of the following statements by the client indicates a need for further teaching?

I will be certain to take enteric-coated medications

A nurse is reinforcing preoperative teaching with a client who is to undergo a bowel resection at 1300 next week. Which of the following statements client indicated to the nurse a need for further teaching?

I will take my warfarin with a glass of water the night before my surgery

A nurse is reinforcing teaching with a client who has cholelithiasis and is scheduled for an endoscopic retrograde cholangiopancreatography. Which of the following statements made by the client indicates an understanding of the teaching?

Ill have an endoscope put down my throat so they can see my gallbladder

A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations should indicate to the nurse the client is experiencing a complication and the provider should be notified immediately?

Increased heart rate

A nurse is reviewing the prescriptions for a client who had a THR. Which of the following prescriptions should the nurse verify with the provider?

Instruct the client to restrict flexion of the hip past 120

A nurse is reviewing the serum laboratory results of four children. Which of the following values should the nurse report to the provider?

Iron 38

A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?

Irritability

A nurse in a provider's office is caring for a client who is at 36 weeks gestation and is scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following responses by the nurse is appropriate?

It assists in identifying the location of the placenta and fetus

A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, what explanation should the nurse give him?

It delivers the low concentration of oxygen you need.

A nurse is assisting with the care of a client who has a newly inserted chest tube. Which of the following actions should the nurse take?

Keep the collection device below the client's chest level

A nurse is assisting with the plan of care for a client who has a chest tube connected to a closed chest drainage system. Which of the following interventions should the nurse include in the plan of care?

Keep the collection device below the level of the client's chest

A nurse is reinforcing teaching about a high-fiber diet with a client who has constipation. Which of the following foods should the nurse include as sources of fiber? (Select all that apply.)

Kidney beans Strawberries Whole wheat bread

A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Limit the number of health care workers entering the room

A nurse is caring for a client who has tuberculosis and Is about to start taking pyrazinamide. The nurse should identify that the client needs which of the following tests while taking this medication therapy?

Liver function tests

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse question?

MRI

A nurse is reinforcing teaching about long-term complications of retinopathy and neuropathy with an older client who has diabetes mellitus. Which of the following actions is the most important for the nurse to include in the teaching?

Maintain stable blood glucose levels

A nurse is caring for a client who has acute kidney injury . The client's ABGs are : pH : 7.26 , PaCO2 : 30 mm Hg , HCO3 : 14 mEq / L . Which of the following acid - imbalances should the nurse identify the client is experiencing ?

Metabolic acidosis

A nurse is reinforcing teaching with a client who has Diabetes mellitus type 1 about sick day management which of the following is the priority to recommend to the client?

Monitor glucose levels every 4 hours

A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium level is 7mg / dL . Which of the following client findings should the nurse expect?

Muscle tetany

A nurse is reinforcing teaching with a male client about a semen analysis to be done for suspected infertility. Which of the following information should the nurse include?

No ejaculation for 2-3 days prior

A nurse is reinforcing teaching with a client who asks which diagnostic test is the preferred method for detecting cervical cancer. Which is an appropriate response by the nurse?

Papanicolaou test

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

Paralytic ileus

A nurse is caring for the client who has Ménière's disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?

Please call for assistance when you wish to get out of bed

A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a prescription for a chest x ray. Which actions should the nurse plan to take in the care of this client?

Place a surgical mask on the client prior to exiting the room.

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and FHR is 140/min. Which of the following actions should the nurse take first?

Place client in the lateral position

A nurse is caring for a client who has a new diagnosis of lung cancer. For each potential provider's prescription at 4 weeks. Click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Place the client in a private room - anticipated Insert an indwelling urinary catheter - contraindicated Place the client on droplet precautions - nonessential Check the client's rectal temp once daily - contraindicated Rinse the client's mouth with 0.9% sodium chloride every 4 hours - anticipated

A nurse is evaluating client laboratory findings. The nurse should identify that an increase in a client's prostate-specific antigen (PSA) level can indicate which of the following conditions?

Prostatitis

A nurse is caring for a client who has a serum potassium level of 5.5. The provider prescribes polystyrene sulfate. Which of the following ECG results should indicate to the nurse that the medication has been effective?

Reduction of T waves amplitude

A nurse is caring for a client who has an absolute neutrophil count(ANC) less than 1,000/mm3. Which of the following interventions should the nurse implement?

Report a temperature of 38.3C(101F) or greater

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN); glucose 72 mg/dL, chloride 100 mEq/L, sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Request potassium replacement

A nurse is caring for a client whose arterial blood gas results show the following: pH 7.2, PaCO2 50, HCO 24

Respiratory acidosis

A home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. Which of the following information should the nurse include in the plan of care?

Rest in semi-fowler's position

A nurse is reinforcing teaching with a client who has cholecystitis about required dietary modifications. Which of the following food choices should the nurse inform the client to include in his diet?

Roast turkey

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

Russell's traction uses a sling under the knee to treat a fracture of the femur

A nurse is planning meals for a 2-year-old child who has a fractured jaw and is having difficulty swallowing. The surgeon has prescribed a pureed diet. Which of the following food selections should the nurse make?

Scrambled eggs

A nurse is preparing a sitz bath for a client who is 1 day postpartum. Which of the following actions should the nurse take?

Set the water temperature to 40 C (104 F)

A nurse is reinforcing discharge instructions for a client following a laminectomy. Which of the following instructions should the nurse take?

Sit in straight back chairs

A nurse is reinforcing discharge teaching with a client who had a total hip arthroplasty. Which of the following information should the nurse include in the teaching?

Sit with legs apart at the ankles

A nurse is reinforcing discharge teaching with a client who has AIDS. Which of the following statements should the nurse make regarding home infection control?

Soak sponges used for cleaning in a bleach solution after use

A nurse is reviewing the preadmission laboratory test results of a client who is scheduled for a carotid endarterectomy in 3 days . Which of the following results should the nurse report to the provider?

Sodium 151

A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?

Temperature

A nurse is assisting with the care of a client who has recently undergone a stem cell transplant. Which of the following isolation precautions should the nurse take?

The client is not permitted to have fresh flowers or potted plants

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram ( IVP). What should the nurse teaching?

The nurse should encourage fluid intake after the procedure to promote elimination of the dye

A nurse in a provider's office is reinforcing teaching with a client who is scheduled for an arthroplasty. When the client asks the nurse what this procedure will do for him, which of the following responses should the nurse make?

The purpose of this procedure is to replace the joint and improve function

A nurse is reinforcing teaching with a client who is scheduled for a blood test to measure her thyroid-stimulating hormone (TSH) level. Which of the following statements should the nurse give?

The test determines whether your thyroid gland is overactive, appropriately active or underactive.

A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear anti embolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

They'll improve you circulation to keep blood from pooling in your legs

A nurse is reinforcing teaching with a client who is taking warfarin about monitoring it's therapeutic effect. The nurse should issue which of the following statements about the provider's use of the international normalized ratio (INR)?

This is a standard test, so it eliminates the variations different laboratories report in prothrombin times

A nurse is reinforcing teaching with a newly licensed nurse about the purpose of an indirect Coombs test. Which of the following statements should the nurse include in the teaching?

This test detects Rh-positive antibodies in the mothers blood

A nurse is reinforcing teaching with a client who is scheduled for a thallium scan. When talking with the client about this procedure, which of the following statements should the nurse give?

This test detects damage to the heart muscle

A nurse is reviewing the plan of care for a client who has cellulitis. Which of the following interventions should the nurse recommend?

Wash daily with antibacterial soap

A nurse is reviewing the diagnostic test results of a female client who is about to undergo knee arthroplasty.Which of the following data collection findings should the first identify as the priority?

WBW COUNT 20,000/mmm3

A nurse is preparing to review discharge instructions with a client who has pulmonary tuberculosis. Which of the following information should the nurse include?

Wear a mask while out or around crowds of people

Nurse is caring for a client who has HF. A nurse is reviewing the assessment finding for the client on day 4. Which of the following findings requires further action?

Weight, blood pressure, breathe sounds, oxygen saturation

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain to the client that, after the laboratory has the enzyme immunoassay (EIA), it will use which of the following tests to confirm the diagnosis

Western blot assay

A nurse is caring for a client who has just had a bronchoscopy. Which of the following actions should the nurse take?

Withhold food and liquids until clients gag reflex returns

A nurse is reinforcing preoperative teaching to a client who is to undergo a radical prostatectomy. Which of the following statements should the nurse include in the teaching?

You may feel the need to urinate even though a catheter Performing Kegel exercises following the surgery will help you to manage incontinence You should expect your urine to be blood-tinged for a few days following the surgery.

A nurse is reinforcing preoperative teaching with a client who is scheduled for cataract surgery. Which of the following statements should the nurse make?

You should expect your vision to improve within 2 weeks of surgery